Influenza vaccination in individuals with egg allergy
- John M Kelso, MD
John M Kelso, MD
- Section Editor – Anaphylaxis
- Division of Allergy, Asthma, and Immunology
- Scripps Clinic, San Diego, CA
- Julie Wang, MD
Julie Wang, MD
- Associate Professor of Pediatrics
- Icahn School of Medicine at Mount Sinai
The majority of the intramuscular inactivated influenza vaccines (IIVs) and the intranasal live-attenuated influenza vaccine (LAIV) are cultured on fluid from chicken embryos. As a result, there is a small amount of egg protein in these vaccines. Thus, there is a theoretical risk of inducing an allergic reaction when administering the influenza vaccine to an individual with egg allergy. However, many of these same patients are also at higher risk of an adverse outcome due to influenza infection (eg, age <2 years, history of asthma) and would therefore benefit from vaccination.
This topic reviews the risks and benefits of administration of the influenza vaccine in patients with egg allergy. Other issues related to egg allergy (including prevalence) and allergic reactions to vaccines are discussed separately. (See "Egg allergy: Clinical features and diagnosis" and "Allergic reactions to vaccines".)
The measles, mumps, and rubella (MMR) vaccine is not contraindicated in patients with egg allergy. This is discussed in detail separately. (See "Allergic reactions to vaccines", section on 'Measles, mumps, and rubella' and "Egg allergy: Management", section on 'Egg-containing vaccines and lipid emulsions'.)
RISKS ASSOCIATED WITH INFLUENZA INFECTION
Both seasonal and pandemic influenza infection can lead to severe infection and death, particularly in certain high-risk groups. Seasonal influenza results in higher mortality rates among patients with certain chronic medical conditions (eg, asthma), pregnant women, and those at the extremes of age. (See "Clinical manifestations of seasonal influenza in adults", section on 'Complications of influenza' and "Seasonal influenza in children: Clinical features and diagnosis", section on 'Complications' and "Influenza and pregnancy", section on 'Clinical course in pregnancy'.)
Influenza vaccination is recommended for all individuals six months of age and older and is particularly important in those at increased risk of complications. (See "Seasonal influenza vaccination in adults" and "Seasonal influenza in children: Prevention with vaccines", section on 'Target groups'.)
- Kelso JM, Greenhawt MJ, Li JT, et al. Adverse reactions to vaccines practice parameter 2012 update. J Allergy Clin Immunol 2012; 130:25.
- Woo EJ. Allergic reactions after egg-free recombinant influenza vaccine: reports to the US Vaccine Adverse Event Reporting System. Clin Infect Dis 2015; 60:777.
- Nagao M, Fujisawa T, Ihara T, Kino Y. Highly increased levels of IgE antibodies to vaccine components in children with influenza vaccine-associated anaphylaxis. J Allergy Clin Immunol 2016; 137:861.
- Bohlke K, Davis RL, Marcy SM, et al. Risk of anaphylaxis after vaccination of children and adolescents. Pediatrics 2003; 112:815.
- Tavares F, Delaigle A, Slavin D, et al. Anaphylaxis following H1N1 pandemic vaccines: safety data in perspective. Vaccine 2011; 29:6402.
- Vasu N, Ghaffari G, Craig ET, Craig TJ. Adverse events associated with intranasal influenza vaccine in the United States. Ther Adv Respir Dis 2008; 2:193.
- McNeil MM, Weintraub ES, Duffy J, et al. Risk of anaphylaxis after vaccination in children and adults. J Allergy Clin Immunol 2016; 137:868.
- Vellozzi C, Burwen DR, Dobardzic A, et al. Safety of trivalent inactivated influenza vaccines in adults: background for pandemic influenza vaccine safety monitoring. Vaccine 2009; 27:2114.
- Waibel KH, Gomez R. Ovalbumin content in 2009 to 2010 seasonal and H1N1 monovalent influenza vaccines. J Allergy Clin Immunol 2010; 125:749.
- Li JT, Rank MA, Squillace DL, Kita H. Ovalbumin content of influenza vaccines. J Allergy Clin Immunol 2010; 125:1412.
- McKinney KK, Webb L, Petersen M, et al. Ovalbumin content of 2010-2011 influenza vaccines. J Allergy Clin Immunol 2011; 127:1629.
- James JM, Zeiger RS, Lester MR, et al. Safe administration of influenza vaccine to patients with egg allergy. J Pediatr 1998; 133:624.
- Chung EY, Huang L, Schneider L. Safety of influenza vaccine administration in egg-allergic patients. Pediatrics 2010; 125:e1024.
- Gagnon R, Primeau MN, Des Roches A, et al. Safe vaccination of patients with egg allergy with an adjuvanted pandemic H1N1 vaccine. J Allergy Clin Immunol 2010; 126:317.
- Greenhawt MJ, Chernin AS, Howe L, et al. The safety of the H1N1 influenza A vaccine in egg allergic individuals. Ann Allergy Asthma Immunol 2010; 105:387.
- Owens G, MacGinnitie A. Higher-ovalbumin-content influenza vaccines are well tolerated in children with egg allergy. J Allergy Clin Immunol 2011; 127:264.
- Howe LE, Conlon AS, Greenhawt MJ, Sanders GM. Safe administration of seasonal influenza vaccine to children with egg allergy of all severities. Ann Allergy Asthma Immunol 2011; 106:446.
- Webb L, Petersen M, Boden S, et al. Single-dose influenza vaccination of patients with egg allergy in a multicenter study. J Allergy Clin Immunol 2011; 128:218.
- Fung I, Spergel JM. Administration of influenza vaccine to pediatric patients with egg-induced anaphylaxis. J Allergy Clin Immunol 2012; 129:1157.
- Des Roches A, Paradis L, Gagnon R, et al. Egg-allergic patients can be safely vaccinated against influenza. J Allergy Clin Immunol 2012; 130:1213.
- Greenhawt MJ, Spergel JM, Rank MA, et al. Safe administration of the seasonal trivalent influenza vaccine to children with severe egg allergy. Ann Allergy Asthma Immunol 2012; 109:426.
- Des Roches A, Samaan K, Graham F, et al. Safe vaccination of patients with egg allergy by using live attenuated influenza vaccine. J Allergy Clin Immunol Pract 2015; 3:138.
- Turner PJ, Southern J, Andrews NJ, et al. Safety of live attenuated influenza vaccine in atopic children with egg allergy. J Allergy Clin Immunol 2015; 136:376.
- Turner PJ, Southern J, Andrews NJ, et al. Safety of live attenuated influenza vaccine in young people with egg allergy: multicentre prospective cohort study. BMJ 2015; 351:h6291.
- Reisinger KS, Block SL, Izu A, et al. Subunit influenza vaccines produced from cell culture or in embryonated chicken eggs: comparison of safety, reactogenicity, and immunogenicity. J Infect Dis 2009; 200:849.
- Szymczakiewicz-Multanowska A, Groth N, Bugarini R, et al. Safety and immunogenicity of a novel influenza subunit vaccine produced in mammalian cell culture. J Infect Dis 2009; 200:841.
- Cox MM, Patriarca PA, Treanor J. FluBlok, a recombinant hemagglutinin influenza vaccine. Influenza Other Respir Viruses 2008; 2:211.
- Chichester JA, Haaheim LR, Yusibov V. Using plant cells as influenza vaccine substrates. Expert Rev Vaccines 2009; 8:493.
- Allgaier S, Taylor RD, Brudnaya Y, et al. Vaccine production in Neurospora crassa. Biologicals 2009; 37:128.
- Kang SM, Song JM, Quan FS, Compans RW. Influenza vaccines based on virus-like particles. Virus Res 2009; 143:140.
- Frey S, Vesikari T, Szymczakiewicz-Multanowska A, et al. Clinical efficacy of cell culture–derived and egg‐derived inactivated subunit influenza vaccines in healthy adults. Clin Infect Dis 2010; 51:997.
- Barrett PN, Berezuk G, Fritsch S, et al. Efficacy, safety, and immunogenicity of a Vero-cell-culture-derived trivalent influenza vaccine: a multicentre, double-blind, randomised, placebo-controlled trial. Lancet 2011; 377:751.
- US Food and Drug Administration. FDA news release. FDA approves first seasonal influenza vaccine manufactured using cell culture technology. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm328982.htm (Accessed on November 26, 2012).
- Flucelvax prescribing information. www.novartisvaccinesdirect.com/pdf/Flucelvax_PI.pdf (Accessed on November 28, 2012).
- Flucelvax prescribing information http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM502899.pdf (Accessed on June 07, 2016).
- Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines. MMWR Recomm Rep 2016; 65:1.
- US Food and Drug Administration. FDA news release. FDA approves new seasonal influenza vaccine made using novel technology www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm335891.htm (Accessed on January 17, 2013).
- US Food and Drug Administration. October 29, 2014 Approval Letter - Flublok. Accelerated supplement approval. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm421396.htm (Accessed on November 04, 2014).
- Treanor JJ, El Sahly H, King J, et al. Protective efficacy of a trivalent recombinant hemagglutinin protein vaccine (FluBlok®) against influenza in healthy adults: a randomized, placebo-controlled trial. Vaccine 2011; 29:7733.
- Treanor JJ, Schiff GM, Hayden FG, et al. Safety and immunogenicity of a baculovirus-expressed hemagglutinin influenza vaccine: a randomized controlled trial. JAMA 2007; 297:1577.
- King JC Jr, Cox MM, Reisinger K, et al. Evaluation of the safety, reactogenicity and immunogenicity of FluBlok trivalent recombinant baculovirus-expressed hemagglutinin influenza vaccine administered intramuscularly to healthy children aged 6-59 months. Vaccine 2009; 27:6589.
- Summary Recommendations: Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—(ACIP)—United States, 2013-14 http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#egg-allergy.
- Committee on Infectious Diseases, American Academy of Pediatrics Policy Statement: Recommendations for Prevention and Control of Influenza in Children, 2013–2014. http://pediatrics.aappublications.org/content/early/2013/08/28/peds.2013-2377.
- National Institute of Allergy and Infectious Diseases: Updated recommendations on influenza vaccine and people with egg allergy. http://www.niaid.nih.gov/topics/vaccines/research/Pages/eggAllergy.aspx (Accessed on September 20, 2011).
- Committee on Infectious Diseases, American Academy of Pediatrics. Recommendations for prevention and control of influenza in children, 2012-2013. Pediatrics 2012; 130:780.
- Kelso JM, Greenhawt MJ, Li JT, Joint Task Force on Practice Parameters (JTFPP). Update on influenza vaccination of egg allergic patients. Ann Allergy Asthma Immunol 2013; 111:301.
- An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI) Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2015-2016. 2015. http://www.phac-aspc.gc.ca/naci-ccni/flu-2015-grippe-eng.php (Accessed on April 27, 2016).
- COMMITTEE ON INFECTIOUS DISEASES. Recommendations for Prevention and Control of Influenza in Children, 2016-2017. Pediatrics 2016; 138.
- Centers for Disease Control and Prevention. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). 2011 report. http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf (Accessed on September 20, 2013).
- RISKS ASSOCIATED WITH INFLUENZA INFECTION
- RISK OF ANAPHYLAXIS TO VACCINES
- Fatal anaphylaxis
- VACCINE EGG PROTEIN CONTENT
- SAFETY OF VACCINES IN PATIENTS WITH EGG ALLERGY
- ALTERNATIVE METHODS OF VACCINE PRODUCTION
- APPROACH TO EVALUATION AND VACCINE ADMINISTRATION
- Risk assessment
- Vaccine choice
- Our approach
- SUMMARY AND RECOMMENDATIONS